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STATE OF CALIFORNIP WATER RESOURCES CONTROWARD FORM AA': UNDERGROUND STORAGE TANK PROGRAM "T "°� Z SITE C FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION _ m to C4UiOPN�P COMPLETE THIS FORM FOR EAC ACILITY/SITE NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED MARK ONLY SITE N ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1..1 I.FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 1 FACIU /SITE NAMECARE OF ADDRESS INFORMATION �+ � Plum e TE AGENCY ADDRESS NEAREST CROSS STREET 0 CDINmrI0N 0 Liidditi, [3 OCALAG90 ❑ FTAEDMAGENCY n O A/ ❑ INVITUAL ❑ CDUN7Y AGENCY OC fT STATE ZIP CODE SITE PHONE X,WITH AREA CODE CITY NAME CA .S TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 81 If INDIAN EPA ID N Xof TANK's ❑ 1 GAS STATION �3 FARM OTHER RESERVATION or ❑ AT THIS SITE J EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST(FIRST) PHONE N WITH AREA CODE 3- 7108"/ NIGHTS: NAME(LAS .FIRST) - PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE Il. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME n�t PARTNERSHIP ❑ STATE-AGENCY MAILING or STREET ADDRESS ✓ indicate ❑ ORPORATION 11 LOCAL-AGENCY 11 FEDERAL-AGENCY -•.: ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE I PHONE N,WITH AREA CODE I qsava Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME � CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl RPOUATON ❑ LOCAL-AGENCY AL-AGECY 0 FEDERAL-AGENCY ❑ IN STATE ZIP CODE 'PHONE N,WATT AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS 1, CHECK ONE(f)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION If AGENCY N FACILITY IDN N of TANKS M SITE zo EEE37 v I CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE M WITH AREA CODE PTHIS UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �� LOCATION CO E CEN ACT N _ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE �/ OGI,/] YES NO 2-Y' CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BY: IM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY-68) DATA PROCESSING COPY